Lecture Three: Care of the Client During Pregnancy

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Lecture Three Care of the Client During Pregnancy

• NURS 2208
• T. Dennis RNC, MSN

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Objectives

• Examine various prenatal education programs,
  alternative birthing options, and nursing
  implications.
• Describe the different signs of pregnancy.
• Explain normal physical, physiologic, and
  psychological changes occurring in a woman
  throughout pregnancy.

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Preparation for Parenthood

• Begins in the family setting
• Attitudes, feelings, ideas, fears
• Knowledge-accurate or inaccurate
• Comfort zone - no comfort zone

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The nurse fosters involvement by the family to
help them cope with feelings of anxiety

• Childbearing family-a variety of combinations
• Helps in decision making by informing the client
  of choices available-informed choices
• Reaffirms the clients ability to make decisions

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Pre-Conception Counseling

• Teaching- No smoking, no caffeine, no OTCs
• Physical Exam- Both partners (optimal health)
• Nutrition
• Exercise
• Conception (RELAX)

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Childbearing Decisions.Who will take care of me?

• Types of providers available
• Interview the provider
• Ask questions nownot when pushing
• Visit different providers

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The Birth Plan

• Assists clients /couples in making choices
• Encourages research into available options
• Tool for communication- Are we all on the same
  page?
• Helps client/couples set priorities
• Adds realization of limitations to the experience
  that may occur

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It is important for the nurse to be
nonjudgmental and yet helpful to the
client/couple in keeping their expectations
realistic
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The Labor Support Person

• The Coach Role
• The Teammate Role
• The Witness Role
• The Doula
• The Monitrice

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Siblings at the Birth

• Preparation is key (AV, classes, books)
• Child has own support person
• Allowed to participate (as long as not
  disruptive)
• Generally a good experience
• Fosters acceptance of the new infant

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Classes for Family Members

• Early Prenatal classes
• Later Prenatal classes
• Adolescent parenting classes

• Breastfeeding programs
• Sibling preparation
• Classes for grandparents

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Education for Cesarean Birth

• Preparation for cesarean birth
• Preparation for repeat cesarean birth
• Preparation for Vaginal Birth After Cesarean
  Section (VBAC)

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Methods of Childbirth Education

• LAMAZE (psychoprophylactic)
• KITZINGER (sensory memory)
• BRADLEY (partner coached)

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Lamaze

• Mind prevention
• Major components are education and training
• Body conditioning exercises (pelvic tilt, pelvic
  rock, Kegels)
• Relaxation exercises (Progressive, touch,
  disassociated)
• Breathing techniques

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Advantages to Childbirth Education Classes

• Reduced need for analgesics and/or anesthetics
• Parental satisfaction (a shared journey, a sense
  of control over the process)
• Each method has been shown to shorten the labor
  process (relax, relax, relax)

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INDIVIDUALITY

• Vocalization or sounding
• Massage (increases relaxation)
• Breathing (any manner/technique)
• Warm water (compresses, bath, shower)
• Visualization
• Relaxing music - subdued lighting
• Aromatherapy
• The Birthing ball or Birthing bar

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Changes occurring in pregnancy

• Uterus circulatory requirements increase, walls
  thicken until late pregnancy when they become
  thinner, Braxton Hicks contractions occur
  intermittently.
• Cervix Goodells sign (softening of the cervix),
  Chadwicks sign (blue-purple discoloration
• Ovaries cease ovum production during pregnancy.

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Changes occurring in pregnancy

• Vagina may show same bluish color as Chadwicks
  sign
• Breasts size and nodularity increase, striae
  (stretch marks) may appear, colostrum (an
  antibody rich, yellow secretion, may be expressed
  manually by 12th week and will eventually convert
  to milk.
• Respiratory system diaphragm elevated and rib
  cage flares during latter part of pregnancy.

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Changes occurring in pregnancy

• Cardiovascular system hear pushed upward, blood
  volume increases, supine hypotensive syndrome or
  vena caval syndrome or aortocaval compression may
  occur producing a drop in blood pressure with
  dizziness,pallor and clamminess (may be relieved
  by turning to left side).

• Clotting changes place the pregnant woman at risk
  for developing venous thrombosis.
• Physiologic anemia of pregnancy anemia that
  results during pregnancy due to the plasma volume
  increasing more than the erythrocytes.

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Changes occurring in pregnancy

• Gastrointestinal system nausea vomiting of
  pregnancy, peculiarities of taste and smell, gums
  may bleed.Heartburn occurs due to relaxation of
  the cardiac sphincter. Bloating and constipation
  may occur.
• Urinary tract Frequency occurs due to pressure
  of growing uterus on bladder, more prone to
  infections.

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Changes occurring in pregnancy

• Skin and hair Pigmentation of skin may increase,
  linea nigra (linea alba, midline from pubic area
  to umbilicus) darkens, chloasma (mask of
  pregnancy) appears. Striae may appear. Vascular
  spider nevi, small, bright red elevations of the
  skin radiating from a central body. Rate of hair
  growth slows and hair loss may occur.

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Changes occurring in pregnancy

• Musculoskeletal system Lordosis (spinal
  curvature) may occur in late pregnancy. Waddling
  gate may occur in late pregnancy.
• Eyes Intra-ocular pressure decreases. A slight
  thickening of the cornea occurs (makes contact
  lens slightly uncomfortable). These changes
  usually resolve by 6 weeks post partum.

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Changes occurring in pregnancy

• Metabolism 25 - 35 lb weight gain is
  recommended. An increase in water retention
  occurs. Demand for iron is accelerated. The
  demand for carbohydrates increases.
• Endocrine system Thyroid usually slightly
  enlarged due to increased vascularity and
  hyperplasia of glandular tissue.

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Signs of Pregnancy

• Subjective Presumptive changes that are the
  symptoms the client experiences and reports.
• Objective Probable changes that occur in
  pregnancy that are more diagnostic than
  subjective symptoms.
• Diagnostic Positive signs that are completely
  objective and offer conclusive proof of pregnancy.

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Presumptive Signs of Pregnancy(Subjective)

• Amenorrhea
• Nausea and vomiting of pregnancy (NVP or morning
  sickness)
• Excessive fatigue
• Urinary frequency
• Breast changes
• Quickening

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Probable Signs of Pregnancy(Objective)

• An observer can perceive the objective signs that
  occur in pregnancy.
• Changes in the pelvic organs (Chadwicks sign,
  Goodells sign, Hegars sign , McDonalds sign)
• Enlargement of the abdomen (during childbearing
  years)
• Uterine souffle

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Probable Signs of Pregnancy(Objective)

• Changes in pigmentation of the skin and the
  appearance of abdominal striae
• The fetal outline may be identified by palpation
  after 24 weeks gestation
• Ballottement may be felt on vaginal exam
• Pregnancy tests based on hCG
• Over-the-counter pregnancy tests

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Diagnostic (positive) Signs of Pregnancy

• Completely objective, conclusive proof of
  pregnancy , not confused with other pathological
  states
• Fetal heart rate
• Fetal movement palpated by an examiner after 20
  weeks gestation
• Visualization of the fetus by ultrasound (fetal
  parts and heart rate visible at 8 wks)

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Question

• Suzanne Martin comes to her prenatal check
  up. She tells the nurse that she thinks she is 10
  weeks pregnant. Which one of the following would
  be a probable (objective) sign of pregnancy?
• Human chorionic gonadotrophin (hCG) in the urine
• Breast tenderness
• Morning sickness
• Fetal heart tones

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Psychological Response in Pregnancy

• Anxiety pregnancy is a developmental turning
  point as childless couples become parents.
• Lifestyle changes occur.
• The reality of labor and birth. How will my life
  change after I have a baby?
• Social support is important.
• Affects both mother, father, siblings and
  grandparents.

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• Father
• Ambivalence about being a parent.
• Concern of moving into a parenting role.
• Stress due to financial issues, changing
  relationship with partner, his role in the
  pregnancy.
• Concern about their ability to parent.
• May exhibit signs or symptoms related to the
  pregnancy.

• Mother
• Ambivalence
• Acceptance
• Introversion
• Mood swings
• Changes in body image

Siblings
Sibling rivalry Regression
GRANDPARENTS
Unsure of their role Support resource
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Cultural Diversity and Pregnancy

• Health values ritualistic since ancient man,
  normal occurrence, sign of virility,
  generalizations are inappropriate.
• Health beliefs time of vulnerability,equilibrium
  model (hot/cold)
• Health practices home remedies, healthcare
  professionals, importance of indigenous healers.

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Cultural factors and Nursing care

• Become aware of cultural differences
• Identify personal biases
• Learn rituals and customs of other cultures
• Include cultural assessment

• Foster an attitude of respect
• Provide for interpreters
• Learn the language or key phrases
• Incorporate practices into care

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Initial Client History (pg. 252)

• Gravida and para refer to pregnancies not to the
  fetus.
• TPAL is a useful acronym helpful in remembering
  term used to identify the number of infants born
  (T) number of term infants born, (P) number of
  preterm infants born, (A) number of abortions,
  (L) number of children currently living.

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Question

• Madeline is 8 weeks pregnant. She has a baby girl
  born at 35 weeks that is living and well, a
  pregnancy that ended in a stillbirth at 41 weeks,
  and a spontaneous abortion at 12 weeks gestation.
  Determine Madelines gravity and parity using the
  TPAL system.
• 3-1-1-1-1
• 3-0-1-1-1
• 4-0-1-2-1
• 4-1-1-1-1

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Determination of Due Date (pg. 268)

• EDC Estimated date of confinement
• EDD Estimated date of delivery
• EDB Estimated date of birth
• Nägeles Rule Begin with the first day of the
  last menstrual period, subtract three months, and
  add seven days (most common method of determining
  the EDB)

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Antepartum Assessment

• Uterine Assessment Uterine size may be one of
  the single most important clinical method for
  dating pregnancy ( in the first 10-12 weeks,
  dates accurate).
• Fundal height A centimeter tape is used to
  measure the distance from the top of the
  symphysis pubis over the curve of the abdomen to
  the top of the uterine fundus.
• Pelvic adequacy Clinical pelvimetry is performed
  by a nurse with special preparation.

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Danger Signs in Pregnancy

• Persistent vomiting
• Severe headache
• Edema of hands, feet, face and legs
• Muscular irritability, convulsions
• Epigastric pain
• Oliguria, Dysuria
• Absence of fetal movement

• Sudden gush of fluid from vagina
• Vaginal bleeding
• Abdominal pain
• Temperature gt 101 and chills
• Dizziness, blurring of vision, spots before eyes

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Subsequent Prenatal Visits

• Every four weeks for the first 28 weeks
• Every 2 weeks until 36 weeks gestation
• After 36 weeks, every week until childbirth
• These are general guidelines. The frequency of
  visits should be based on the clients individual
  needs and assessment of her risks.

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Common Discomforts of Pregnancy - First Trimester

• Nausea and vomiting Dry carbohydrate snack
  before getting OOB, small frequent meals ,
  acupressure.
• Urinary frequency/stress incontinence empty
  bladder frequently, good hygiene, Kegel exercises
• Fatique frequent rest periods
• Breast-tenderness wear good support bra
• Increased vaginal discharge good hygiene
• Nasal stuffiness and nosebleed (epistaxis)
  humidify air, vitamin C, lubricate nostrils
• Ptyalism (excessive, often bitter salivation)

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Common Discomforts of Pregnancy - 2nd 3rd
Trimesters

• Heartburn (pyrosis) small frequent meals, avoid
  fried, greasy or spicy foods
• Ankle edema elevate feet, wear support hose,
  decrease sodium in diet
• Varicose veins support hose
• Hemorrhoids, flatus and constipation increase
  exercise, increase fluids and roughage in diet
• Backache pelvic tilt exercises, good posture
• Difficulty sleeping/pelvic heaviness side lying
  position, knee to chest

• Leg crampsflex toes toward face and hyper extend
  foot, increase calcium/phosphorous levels
• Faintness avoid sudden position change or supine
  position
• Dyspnea arms over head, slow breathing stretch
  to elongate trunk
• Round ligament pain no sudden turns, support
  abdomen
• Carpal tunnel syndrome

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Dietary Teaching

• Achieve a protein intake of 60 gms per day
• Maintain a calcium intake of 1200 mg per day.
• Folic acid intake of 400mcg per day is desired.
• An appropriate weight gain of 3.5 to 5 lb per
  week during the first trimester and 1 lb per week
  thereafter.
• Avoid fried foods to relieve heartburn.
• No caloric increase during the first trimester
• Increase caloric intake by 300 kcal during the
  second and third trimester.

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Nutrition

• Folic acid sources fresh green leafy vegetables,
  liver, peanuts, and whole grain breads and
  cereals.
• Iron lean meats, dark green leafy vegetables,
  eggs, and whole-grain and enriched breads, dried
  fruits, legumes, shellfish, and molasses. (Iron
  absorption is improved when taken in conjunction
  with a food rich in vitamin C.)
• Vitamin C citrus fruit, tomatoes, cantaloupe,
  strawberries, broccoli, and leafy green
  vegetables.

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Questions?
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Medical Blooper

• A young female patient had come into our
  office for a diaphragm fitting. The doctor
  explained that for easier insertion the diaphragm
  should be lubricated with jelly. Upon her return
  to the office, the doctor noted that the cervix
  was remarkably discolored. When the doctor asked
  her what kind of jelly she used, she replied,
  Grape.

A chuckle a day from the medical community.